Free wellness visit! (Health care extra)

When it's time for your annual physical, you know how you typically think of medical stuff to ask the doctor?

Well, don't do that anymore. Stop thinking. And keep your mouth shut unless you have a serious health concern, such as erectile dysfunction or pending death.

That was the lesson learned by Diane R., a 52-year-old Boylston resident who didn't want her name used, lest her health care provider suddenly decide that hey, those important tests actually aren't covered under section R2D2, and she also happens to need a daily colonoscopy.

Diane underwent a physical in November, now called a wellness visit, which is covered under her health insurance plan with no co-pay. During the visit, she happened to mention a minor ankle pain. The doctor looked at it and the ankle appeared normal, so he basically told her she could get an X-ray if the pain didn't subside.

Two months later, Diane and her husband were surprised to receive a doctor's bill for a $45 co-pay for the physical. Her husband called UMass Memorial Medical Center and was told that, yes, the exam was free. But the co-pay was charged because Diane had the temerity, during her annual physical, to ask about a medical condition. If you can believe the nerve. So in a nifty sidestep of the space-time continuum, she was charged for a second visit within the same time frame of the original visit.

Diane's husband was understandably baffled. He followed up with a call to Tufts Health Plan, his wife's insurer, and got the same answer. He was also told that Tufts was billed $277 for the “physical,” and $188 for the casual ankle question, which took her doctor a whopping two minutes to answer. The bills reflected two visits on the same date and time.

“According to Einstein, this time-multiplier phenomenon doesn't exist, but I guess it does in the world of medical billing,” Diane's husband said.

Clearly, we laypeople lack the advanced medical training needed to understand that a medical exam should not include actual medical questions for the doctor. These days, annual “wellness visits” are intended for basic maintenance, and you're not supposed to bother the doctor with arcane problems such as back pain, fatigue, your bum knee or the 12-inch machete protruding from your forehead. All of those issues cost extra.

Free annual wellness visits have been offered by Medicare since January 2011 as part of the Affordable Care Act signed into law by President Barack Obama, and Medicare's protocol often becomes standard throughout the health care industry. The ACA targets waste, fraud and abuse, and the Department of Health and Human Services has been instructed to impose “quality and efficiency” measures on hospitals and doctors.

“The bottom line is, (wellness visits) are indeed a tricky area,” said Dr. David Fairchild, senior vice president for clinical integration at UMass. “The annual physical doesn't cover problems. The doctor is obligated legally to bill those as separate complaints because they're not a health maintenance issue.”

I told Dr. Fairchild about another instance in which a patient at a wellness visit tried to tell her doctor about a medical problem, but the doctor told her to stop talking or he'd have to charge her.

“As gruff as that sounds, that may be the most appropriate way to communicate,” he said. “Most people don't know what their insurance covers. Doctors and patients need to talk about the billing implications.”

Dr. Fairchild said he's sympathetic to Diane R. and understands her confusion.

“I'd be mad, too, if I was that patient,” he said. “But we as providers are having it drilled into us that if we provide a service, you have to charge for it. Medicare makes a big deal out of fraud. And it's actually fraud to provide a service and not bill for it. We have to make sure we're billing and coding appropriately.”

But Diane's husband called the system a scam and wondered if it was a way to get around the “free” wellness visits. Regardless, he said both doctors and patients are now caught in a medical Catch-22.

“If they warn the patients not to speak because of extra costs, it inhibits the care and makes patients angry,” he said. “If they don't say anything, patients get billed later on and get angry. Am I ticked off about paying the $45? Nope. I'm ticked off that an environment is set up that makes a patient think twice before speaking up about a health problem. I don't think we should be getting health care for free, but we should have a fair, transparent system.”

He thanked me for listening. I told him his first sentence was free, but I'd have to charge extra for the rest.

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